Page 46 nursing.elitecme.com Complete Your CE Test Online - Click Here In hyperaldosteronism, serum bicarbonate levels are often elevated accompanied by alkalosis. Other tests show significantly increased urinary aldosterone levels, increased plasma aldosterone levels, and in secondary hyperaldosteronism, increased levels of plasma renin[5] . Typically the plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio test is used as a screening tool for hyperaldosteronism. This test measures the plasma PAC to PRA ratio. A high ratio of PAC to PRA suggests primary hyperaldosteronism, but additional testing is usually performed to confirm diagnosis[27] . Tests used to confirm primary hyperaldosteronism include[27] : ● ● Captopril suppression test: Patients are given a single dose of the antihypertensive drug captopril after which plasma aldosterone and renin are measured. In patients with primary hyperaldosteronism blood levels of aldosterone remain high and renin levels are low. ● ● 24-hour urinary excretion of aldosterone test: Patients ingest a high- sodium diet for 5 days after which the amount of aldosterone in the urine is measured. In patients with primary hyperaldosteronism, aldosteronism will not be suppressed by the salt load, and the level of aldosterone in the urine will be high [27] . ● ● Saline suppression test: Patients are given intravenous salt solutions after which blood levels of aldosterone and renin are measured. In patients with primary hyperaldosteronism the level of aldosterone in the blood is still high, and the level of renin is low even after this salt loading[27] . A suppression test is also helpful in differentiating between primary and secondary hyperaldosteronism. Patients receive oral desoxycorticosterone for 3 days while plasma aldosterone levels and urinary metabolites are continuously measured. In secondary hyperaldosteronism, levels decrease but levels remain the same in primary hyperaldosteronism[5] . Treatment and nursing considerations Treatment measures for unilateral hyperaldosteronism (only one adrenal gland is affected) include surgical adrenalectomy of the affected gland, administration of a potassium sparing diuretic, and restriction of sodium [5] . In the presence of bilateral adrenal hyperplasia, administration of spironolactone (the drug of choice) is recommended for the management of primary hyperaldosteronism [5,14] . Eplerenone, an aldosterone-blocking antihypertensive, may also be prescribed as well as steroid hormone replacement therapy[5,14] . Treatment of secondary hyperaldosteronism focuses on correction of the underlying cause and management of the clinical manifestations of the hyperaldosteronism[5,26] . Special nursing considerations include[5] : ● ● Monitoring for signs of tetany and hypokalemia such as cardiac arrhythmias, weakness, and paresthesia. Teach patients to recognize these signs and to report them to their HCPs promptly. ● ● Monitoring for signs of rising serum potassium levels and signs of adrenal hypofunction (especially hypertension) after adrenalectomy. ● ● Collaborating with the dietician, patients, and families, to develop a low sodium, high potassium diet. ● ● Teach patients who are taking the potassium-sparing diuretic spironolactone to be alert to the development of signs of hyperkalemia. Patients should be informed that long-term use of this drug may lead to impotence and gynecomastia. ● ● Advise patients who are taking steroid hormone replacement therapy to wear a medical identification bracelet. Cushing’s syndrome Brenda is a 30-year-old financial counselor. She suffers from rheumatoid arthritis and has taken prednisone for a significant period of time in an attempt to control the increasingly severe effects of the disease. Lately, Brenda has begun to notice some troubling new symptoms. She complains about gaining weight, and that this excess weight is especially noticeable over the trunk of her body and on her face, which she says has gotten “round.” She feels weak, and minor cuts and scratches “take forever” to heal. Brenda also notices an increase in facial hair over her lip and chin. Brenda attributes these signs and symptoms to the effects of rheumatoid arthritis, which she says has “ruined” her life. Brenda is in no hurry to report these new problems, believing that nothing can be done to resolve them. “I’ll just wait until my next regular doctor’s appointment next month.” When Brenda next sees her physician these new signs and symptoms have gotten worse, and she has begun to experience upper gastric pain, menstrual irregularities, and emotional liability. Her physician is alarmed by Brenda’s appearance and the new signs and symptoms that have arisen. Based on Brenda’s history and presenting clinical picture the physician initiates a diagnostic work-up to confirm her suspicion that Brenda has Cushing’s syndrome. Cushing’s syndrome is a hormonal disorder caused by prolonged exposure of the body’s tissues to excessive levels of adrenocortical hormones, especially cortisol, related corticosteroids, and, to a lesser extent, androgens and aldosterone[5,28] . Cushing’s syndrome produces a characteristic clinical picture that includes fat deposits of the face, neck, and trunk and purple striae on the skin. Prognosis depends on the underlying cause of the syndrome. Prognosis is poor in persons who do not receive treatment and in people with untreatable ectopic corticotropin producing cancer[5] . Cushing’s syndrome alert! If excess of glucocorticoids is due to a pituitary dependent condition, it is called Cushing’s disease[11] . Review of the role of cortisol The hypothalamus sends corticotropin-releasing hormone (CRH) to the pituitary gland. CRH triggers the pituitary to secrete adrenocorticotropin hormone (ACTH), which stimulates the adrenal glands to release adrenocortical hormones such as cortisol and, to a lesser extent, androgens and aldosterone[5,28] . Cortisol is essential to many critical body functions. Cortisol[28] : ● ● Helps maintain blood pressure and cardiovascular function. ● ● Reduces the inflammatory response of the immune system. ● ● Balances the effects of insulin. ● ● Regulates the metabolism of proteins, carbohydrates, and fats. ● ● Helps the body respond to stress. Cushing’s syndrome alert! Since cortisol helps the body respond to stress, pregnant women in the last 3 months of pregnancy and highly trained athletes have high levels of this hormone[28] . EBP alert! Since research shows that cortisol levels help in the stress response, nurses must know (and anticipate) that such levels are elevated during the last three months of pregnancy and in highly trained athletes. Knowing this can help you explain results to patients and families and avoid unnecessary diagnostic testing if elevated levels in these patients are thought to be abnormal. Under normal conditions, when the amount of cortisol in the bloodstream is adequate, the hypothalamus releases less CRH, which decreases pituitary secretion of ACTH. However, if the adrenal glands, pituitary, or hypothalamus are damaged or diseased, proper regulation of cortisol levels can become skewed[28] .